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Patient Medical Homes: Work smarter, not harder

What are Patient Medical Homes?

PMH is a model adapted from the College of Family Physicians of Canada that describes team-based collaborative care. The idea is the patient always has access to someone— the right provider at the right time—and it’s not always a physician as every team member is encouraged and enabled to work to their full scope. It’s a way for us to work smarter, not harder.

The ultimate goal is to have every single Islander attached to a Patient Medical Home across the province.


What’s the status of Patient Medical Homes on PEI?

We’ve got 12 teams fully committed but at various stages of development. More and more family physicians are stepping up all the time, expressing interest. That’s what I’m here for, as a first point of contact, talking to physicians about the process and what the model could look like for them. Understanding that every team can look a bit different depending on where they are located and the community they are serving. It’s not going to happen overnight and is going to take some time.


What made you decide to get involved?

As a family physician, I am really passionate about providing timely, quality care to my patients. This project is about complete primary care transformation. I like to think of it as people-centered care because the patient is at the center of what we’re doing but everyone involved in the PMH is being taken care of too. There’s a team wrapped around the patient, but they’re also there for each other. I love that concept.

I really believe this is the only way to go. We need to break down silos, have everyone working to their full scope, reduce some duplication in the system, and support one another more. These changes can’t happen fast enough. And, I know there are a lot of changes and things we’re expecting family physicians to accept but it’s critical work that we need to keep pushing forward. Team-based collaborative care is something that’s being recognized nationally as an appropriate strategy to deal with what has become a global human health resource crisis in healthcare systems across the country.


What has been your biggest lesson learned to date, taking on this leadership role and supporting the start-up of these new PMHs?

There are a lot of demands on everyone’s time; it’s not a unique situation. During this process— both personally and professionally— I’ve seen just how important this change is in supporting family doctors in the community. You really, really need to have a good functioning team behind you at your practice in order to be able to facilitate and enable the transition to a Patient Medical Home. We have to work smarter so we’re keeping ourselves healthy, but also providing good, safe care in our practice and a good work environment for our staff. In the end, when the team is working to its full scope and we all have ownership in the care of the patients, everyone is happier; it’s more fulfilling but it’s very challenging to get there.

In order for it to work, you have to take some time to figure out the systems available— such as CHR and Virtual Hallway—and train your staff. And, although it’s all very positive and the outcome is good, there is so much strain on our community-based practices, it can feel impossible to find the time.

That old adage is true— it’s short-term pain for long-term gain. You have to look at the capacity you have in your practice but also within the primary care network around you, find the support you need, and just push through it.


Ideally, what do these PMH teams look like?

We’ve developed an evidence-based staffing model guideline through jurisdictional scanning and have determined that for every nurse practitioner or family physician there should be a medical office assistant and a full nursing support, whether that’s an LPN or an RN. And then, potentially, allied health support based on the clinic’s patient panel and population being served. For example, in one PMH, there is a physiotherapist working on their team because they have a lot of work for him based on their patient panel. He does some of the initial assessment and if he needs to involve a doctor, he can. It may not make sense for all teams to have a physiotherapist in-house, however, our PMH work hopefully enables more seamless access to physiotherapy in that community because there’s a need there. It’s all about being creative and really utilizing the resources we do have most efficiently and optimally in each PMH.


What are the benefits for physicians?

This model will help us provide better access to care for our patients. Additionally, it will allow more physicians to participate in and do quality improvement in a meaningful way so we’re measuring what we do and improving patient outcomes.

The other piece that’s critical for all family physicians is improving the work-life balance— not charting until 10 p.m., not always having to do work on the weekends, actually spreading the workload out, and being able to attend family or social commitments without getting behind in their work.

For family physicians specifically, many of them do provide very needed services in other areas of the healthcare system and this PMH model allows for the team to provide some access and care even when family physicians are offering services outside of their clinic. For example, there are family physicians who provide support in addictions, in-patient care, palliative care, etc.


How does this system benefit other physician groups such as those working in specialty areas?

If our patients can access timely care in a PMH then they won’t be trying to get it either in the emergency room or the internal medicine office, for example. Primary care will be done where it’s supposed to be done in clinics, in the community, and therefore it’ll open up capacity for specialists, emergency doctors and others to do what they are trained to do.


What advice do you give family physicians who—for whatever reason—don’t feel ready to make this move? How do they fit into this fast-evolving primary care model?

We know in the long run that PMH will make life as a family physician easier because we’re seeing that happen in the more evolved Patient Medical Homes; some really great things are happening. However, at the end of the day this is not mandatory, it’s voluntary. A family physician can practice in whatever way they want. There will be people who probably will not want to do this. We still have some family physicians who are not on the CHR, for example. Some have been hesitant and want to wait to see how it rolls out in other communities, and that’s understandable.

It’s an evolution. The upcoming negotiations will play a role and answer some outstanding questions some people have had, but I think it’s fair to say all parties are in agreement there needs to be a focus on primary care and, specifically, community-based family medicine.

We’re at a pivotal moment. Things are evolving and maturing. More and more are raising their hands, wanting to look at developing a Patient Medical Home. I think we’re on the right path, but there’s still a lot of work to be done and some really big pieces that are going to be sorted over the next year that will help enable this transformative process.

We will be doing another formal reach-out soon, engaging those who have been hesitant in another discussion now that there’s been progress across the province. I encourage them to give it a chance and take part in the conversation.


What do Patient Medical Homes mean in terms of infrastructure?

There is a potential need for physical changes to some of the spaces physicians are working in to accommodate additional team members. My practice, for example, has moved to a larger space to accommodate a PMH model because I didn’t have room to accommodate others in the other building. Some spaces can be reconfigured to make it more amenable to having extra team members. There has to be budgeting and planning for that and it doesn’t happen overnight. It’s another reason the rollout is a bit slower than I would like and also why it’s critical we keep all the pieces moving along so we can keep making progress. The other consideration is information technology within the whole infrastructure piece, as updates and adjustments are also needed there.


What do you think healthcare on PEI will look like long-term if we keep with this trajectory?

With Patient Medical Homes, I believe we will have satisfied patients with improved outcomes that we’re able to measure and document. I hope we have providers who are happier in their work and, therefore, we can improve recruitment and retention.

We are generating a lot of interest on the national stage; people are watching us. If we set this up the right way, we might be able to attract more people to come into our province and help us in healthcare. I’m hoping we see our registry list go down over time. I’m hopeful it will give everyone more capacity and reduce the pressure cooker situation for our physicians, specialists, our emergency rooms, walk-ins, etc. I’m hopeful it will create better pathways for patients to get care in their communities, reducing dependency on acute facility bed-based care and meet patients where they are, focusing more on prevention, chronic disease management and keeping people in their homes for longer.


How can physicians learn more or get involved?

Reach out to me. We are working with established teams as well as people who don’t actively have a team but want to be part of one. We’re making connections and looking for ways to wrap a team around you and your patients. Let’s put our heads together and see how a Patient Medical Home can work for you. It starts with a conversation.